Once weekly azithromycin therapy for prevention of Mycobacterium avium complex infection in patients with AIDS: a randomized, double-blind, placebo-controlled multicenter trial.

We conducted a randomized, double-blind, placebo-controlled multicenter trial of azithromycin (1,200 mg once weekly) for the prevention of Mycobacterium avium complex (MAC) infection in patients with AIDS and a CD4 cell count of < 100/mm3. In an intent-to-treat analysis through the end of therapy plus 30 days, nine (10.6%) of 85 azithromycin recipients and 22 (24.7%) of 89 placebo recipients developed MAC infection (hazard ratio, 0.34; P = .004). There was no difference in the ranges of minimal inhibitory concentrations of either clarithromycin or azithromycin for the five breakthrough (first) MAC isolates from the azithromycin group and the 18 breakthrough MAC isolates from the placebo group. Of the 76 patients who died during the study, four (10.5%) of 38 azithromycin recipients and 12 (31.6%) of 38 placebo recipients had a MAC infection followed by death (P = .025). For deaths due to all causes, there was no difference in time to death or number of deaths between the two groups. Episodes of non-MAC bacterial infection per 100 patient years occurred in 43 azithromycin recipients and 88 placebo recipients (relative risk, 0.49; 95% confidence interval, 0.33-0.73). The most common toxic effect noted during the study was gastrointestinal, reported by 78.9% of azithromycin recipients and 27.5% of placebo recipients. Azithromycin given once weekly is safe and effective in preventing disseminated MAC infection, death due to MAC infection, and respiratory tract infections in patients with AIDS and CD4 cell counts of < 100/mm3.

Epidemiology, preventive services, and illnesses of international travelers.

Medical preparation of travelers to overseas locations is an important part of military medical care. We reviewed pre-travel records of patients attending the travel clinic at the National Naval Medical Center (NNMC) and used a post-travel questionnaire to determine the most frequent medical problems associated with international travel. Among 1,416 individuals who received pre-travel care at NNMC, there were 760 (54%) males and 656 (46%) females, the median patient age was 48 years, the most common reason for travel was pleasure, and the median duration of travel was 21 days. The most common destinations were Asia (27%), Africa (15%), Europe (13%), Central America/Caribbean (12%), and South America (11%). The median number of immunizations prescribed was three. Malaria chemoprophylaxis was prescribed to 45%. The average cost of vaccines and medications to medically prepare a traveler was $67. Among 271 (82%) who returned the post-travel questionnaire, the most common illnesses reported were diarrhea (23%) and upper respiratory infections (19%); medical treatment was sought by 9%. Properly informed, military physicians can provide a valuable service at a reasonable cost to reduce the risk of travel-acquired medical problems and illnesses.

A modified ELISA and western blot accurately determine anti-human immunodeficiency virus type 1 antibodies in oral fluids obtained with a special collecting device.

Serum and saliva from 195 known human immunodeficiency virus (HIV)-seropositive patients and 198 military personnel undergoing annual HIV serologic testing were evaluated in a prospective, blinded fashion for anti-HIV-1 antibodies. Oral specimens, collected with a device designed to concentrate oral mucosal transudate from whole saliva, were tested by a modified ELISA and by Western blot. Serum was tested in a standard manner. All 195 HIV-1-seropositive subjects had detectable anti-HIV-1 antibodies in their saliva by ELISA; 190 saliva samples were positive by Western blot and 5 were indeterminate. None of the 198 military personnel were positive by ELISA of serum or oral fluid. The sensitivity, specificity, and positive and negative predictive values for ELISA of saliva were each 100%. The serologic testing of oral mucosal transudate appears to be a simple, safe, sensitive, and specific method for detecting anti-HIV-1 antibodies.

Drug susceptibility of Mycobacterium tuberculosis isolates from recent Haitian migrants: correlation with clinical response.

Between November 1991 and June 1993, approximately 11,000 Haitian migrants were screened for active tuberculosis and human immunodeficiency virus type 1 (HIV-1) infection at the U.S. Naval Base in Guantánamo Bay, Cuba. Cultures of specimens from 37 of these patients yielded Mycobacterium tuberculosis; eight (22%) of these isolates were resistant to standard medications, including isoniazid (22%), rifampin (0), ethambutol (3%), and streptomycin (3%). Two isolates (5.4%) were resistant to two drugs simultaneously. All but one of 340 patients who were treated for presumptive active tuberculosis and who were followed up for about 1 month had a favorable initial clinical response to a standard four-drug regimen. Among 259 HIV-1-infected patients who had normal findings on screening chest radiographs and who received prophylaxis with isoniazid, there were 1.8 incident cases of active tuberculosis per 100 person-years; this rate was 76% lower than that (reported by others) among HIV-1-infected Haitian patients who were not treated with isoniazid. No serious toxic effects due to standard four-drug regimens or to prophylaxis with isoniazid were observed. These data suggest that standard empirical therapeutic interventions for tuberculosis are adequate and well tolerated in Haitian migrants.

Diarrheal and respiratory disease aboard the hospital ship, USNS-Mercy T-AH 19, during Operation Desert Shield.

Diarrhea and respiratory disease were common problems among ground troops deployed to the Middle East during Operation Desert Shield. In order to determine the prevalence and impact of diarrheal and upper respiratory disease among shipboard personnel during this period, an epidemiologic survey was conducted on the hospital ship, USNS Mercy T-AH 19. An episode of acute diarrhea was reported by 46% of the surveyed population, and 79% reported upper respiratory symptoms. Six percent of personnel were temporarily unable to perform scheduled duties due to gastrointestinal symptoms and 7% due to respiratory symptoms. Officers were at increased risk of experiencing an episode of diarrhea, and female crew members more often reported respiratory complaints. Improved strategies to prevent diarrhea and respiratory disease among shipboard personnel are needed.

Hospital-acquired wound mucormycosis.

Cutaneous infections due to fungi of the order Mucorales are uncommon and usually present as a fulminant necrotizing cellulitis. We describe a case of a progressive wound infection at a surgical drain site caused by Rhizopus rhizopodoformis. The indolent nature of the infection and lack of systemic toxicity were atypical features. Mucormycosis should be suspected in cases of slowly progressive cellulitis in the appropriate clinical setting.

Epidemic keratoconjunctivitis at a U.S. military base: Republic of the Philippines.

Between August 1988 and January 1989, 2,603 cases of acute conjunctivitis occurred at Clark Air Base in the Philippines. Clinical features of the disease were consistent with epidemic keratoconjunctivitis. Adenovirus types 19 and 8, as well as enteroviruses, were isolated from conjunctival swabs. Approximately 18% of 9,167 active duty personnel were affected. In an attempt to contain the outbreak, active cases were isolated from the workplace, resulting in 9,038 personnel-days lost. Military preparedness was significantly impacted. A case-control study revealed multiple risk factors for acquisition of the disease.

Plasmodium falciparum-infected Anopheles stephensi inconsistently transmit malaria to humans.

Malaria was transmitted to only 5 of 10 volunteers bitten by 1-2 Anopheles stephensi carrying sporozoites of the 3D7 clone of the NF54 strain of Plasmodium falciparum in their salivary glands. Parasites were detectable by culture in blood taken 7-10 days following exposure and by thick blood film 14-16.5 days after exposure. Infectivity did not correlate with the numbers of sporozoites in the salivary glands.

Diagnosis of acute typhus infection using the polymerase chain reaction.

The first use of the polymerase chain reaction (PCR) for the diagnosis of an acute rickettsial infection is described. A primer pair derived from the 17-kDa antigen sequence of Rickettsia rickettsii gave specific amplification of a 434-base pair DNA fragment from the genome of Rocky Mountain spotted fever and endemic and epidemic typhus. The assay could detect as few as 30 rickettsiae. Detection of PCR-amplified DNA with a nonradioactive DNA probe confirmed an acute infection with Rickettsia prowazekii.

Diagnosis of acute typhus infection using the polymerase chain reaction.

We used the polymerase chain reaction (PCR) for the diagnosis of an acute rickettsial infection. A primer pair derived from the 17-kDa antigen sequence of Rickettsia rickettsii amplified specifically a 434-bp DNA fragment from the genome of Rocky Mountain spotted fever and endemic and epidemic typhus. The assay was able to detect as few as 30 rickettsiae. Detection of PCR-amplified DNA with a digoxigenin-labeled DNA probe confirmed an acute human infection with Rickettsia prowazekii.